ECTOPIC PREGNANCY
 Ektopos - 'out of place'
 Fertilized ovum is implanted and develops outside the normal uterine
cavity
 Most common: ampullary tubal: 70; infundibulum; 11%; isthmus: 12
 In tubal rupture
 Isthmic - 6 to 8 weeks, Rupture
 Ampullary - 8 to 12 weeks, Abortion
 Interstitial - 3 to 4 months
 0.3% of pregnancies among 15- to 19-year-old women
 1% of pregnancies among 24- to 44-year-old women
 16% of women who present with first trimester bleeding, pain, or both,
will ultimately be diagnosed with ectopic pregnancy
 2.7% of all maternal deaths and increases the risk of recurrence in future
pregnancies
 Decrease in mortality rate d/t early diagnosis and treatment. rate of
ectopic pregnancy to be between 1% and 2%.
RISK FACTORS
 Interruption of successful migration of the conceptus to the
endometrium
 High index of suspicion is critical.
 Any condition that delays or interferes with the passage of an embryo
through the fallopian tube increases the risk of ectopic pregnancy
 Most important risk factor: prior ectopic pregnancy with a recurrent risk
of 10% to 15% after first ectopic pregnancy 30% after second ectopic
pregnancy
 Others: history of tubal surgery including tubal ligation, assisted
reproductive technology, and history of pelvic inflammatory disease
(PID).
 Inflammation of the fallopian tube or disruption of tubal motility
including PID, tubal endometriosis, and salpingitis isthmica nodosa.
 Smoking and multiple lifetime sexual partners, are weakly associated
with ectopic pregnancy.
 Intrauterine devices (IUDs) are an effective contraceptive method but
inc risk to be ectopic.
INFERTILITY
 increases with age and parity, and there is a Significant increase in
nulliparous women undergoing infertility treatment.
 associated with specific treatments, including reversal of sterilization,
ovulation induction, and in vitro fertilization (IVF).
 infertility increased the odds of tubal pregnancy at least four times and
perhaps as much as 40 times, depending on etiology of infertility
SMOKING
 Alterations of tubal motility, ciliary activity, and blastocyst implantation are
associated with nicotine intake (dose dependent).
PRIOR ECTOPIC PREGNANCY
 Strongest risk factor for another occurrence.
 d/t previous factors that led to damage to the fallopian tube from the
prior ectopic pregnancy and its treatment.
 Tubal patency is affected by methotrexate (72% of women had bilateral
tubal patency, 19% had unilateral tubal patency, and 3% had bilateral
tubal obstruction.
 HSG is not indicated or cost-effective after methotrexate treatment
TUBAL SURGERY
 tubal surgery is associated with an increased risk for ectopic
 pregnancy,
 Although tubal sterilization remains one of the most effective forms of
contraception and pregnancy is unlikely, failures do occur; when they
do, they are more likely to result in ectopic gestation
 The risk depends on the sterilization technique and the woman’s age at
the time of sterilization:
 postpartum partial salpingectomy and unipolar coagulation have the
lowest rates of ectopic pregnancy while bipolar coagulation techniques
had the highest incidence
 Women younger than 28 years at the time of
 sterilization are more likely to have a failure than women over 34 years.
 Sterilization reversal increases risk for ectopic pregnancy.
  Abdominal pain is the most common presenting symptom. Pain may be
Depends on the method of sterilization, site of tubal occlusion, residual
tube length, coexisting disease, and surgical technique. In general, the
risk of any
 pregnancy after a reanastomosis of a cauterized tube is up to 8% for
laparoscopic procedures.
Pelvic Infection
 Laparoscopically proven PID, the incidence of tubal obstruction
increased with successive episodes of PID: 13% after one episode, 35%
after two, and 75% after three
 Chlamydia is an important pathogen causing tubal damage and
subsequent tubal pregnancy.
 Women at risk for chlamydia infections should be diligently tested,
treated when infection is present, and counseled about the risk of ectopic
pregnancy.
CONTRACEPTIVE USE
 all contraceptive use reduces the overall risk of ectopic pregnancy
 Hormonal and copper-containing IUDs are highly effective at
 preventing intrauterine and extrauterine pregnancies
 In the rare case that women conceive with an IUD in place the pregnancy
is more likely to be ectopic.
DIAGNOSIS
 Asymptomatic cases to acute abdomen and hemodynamic shock. Until
the location of the pregnancy is confirmed, the diagnosis remains a
pregnancy of unknown location.
 Differentials of pregnancy of unknown location: early viable intrauterine
pregnancy, early nonviable intrauterine pregnancy, stable ectopic
pregnancy and unstable
 ectopic pregnancy
 Management of a ruptured ectopic pregnancy is directed at the primary
goal of achieving hemostasis, the management of a pregnancy of
unknown location in a stable patient is varied and depends on many
patient and pregnancy-specific factors.
 Maintain a high degree of suspicion of ectopic pregnancy with
pregnancies of unknown location
 History and physical examination identify patients at risk, improving the
probability of detection of ectopic pregnancy before rupture occurs.
HISTORY
 Include the patient’s age, menstrual history, previous pregnancy,
infertility history, current contraceptive status, risk factor assessment, and
current symptoms.
 Classic symptom triad of ectopic pregnancy is pain, amenorrhea,
and vaginal bleeding (in ruptured ectopic pregnancy)
unilateral or bilateral and may occur in the upper or lower abdomen.
 The patient may experience transient relief of the pain, as stretching of
the tubal serosa ceases. Shoulder and back pain, thought to result from
peritoneal irritation of the diaphragm may indicate intra-abdominal
hemorrhage
Physical Examination
 Findings before rupture and hemorrhage are nonspecific and vital signs
are normal.
 Abdomen may be nontender or mildly tender; may be slightly enlarged
with findings similar to a normal pregnancy
 An adnexal mass may be palpable but the mass varies markedly in size,
consistency, and tenderness.
 Palpable mass may be the corpus luteum and not the ectopic pregnancy.
 With rupture and intra-abdominal haemorrhage:
 Tachycardia followed by hypotension.
 Bowel sounds are decreased or absent.
 Abdomen is distended with marked tenderness and rebound
tenderness
 Cervical motion tenderness is present
ECTOPIC PREGNANCY
 Ektopos - 'out of place'
 Fertilized ovum is implanted and develops outside the normal uterine
cavity
 Most common: ampullary tubal: 70; infundibulum; 11%; isthmus: 12
 In tubal rupture
 Isthmic - 6 to 8 weeks, Rupture
 Ampullary - 8 to 12 weeks, Abortion
 Interstitial - 3 to 4 months
 0.3% of pregnancies among 15- to 19-year-old women
 1% of pregnancies among 24- to 44-year-old women
 16% of women who present with first trimester bleeding, pain, or both,
will ultimately be diagnosed with ectopic pregnancy
 2.7% of all maternal deaths and increases the risk of recurrence in future
pregnancies
 Decrease in mortality rate d/t early diagnosis and treatment. rate of
ectopic pregnancy to be between 1% and 2%.
RISK FACTORS
 Interruption of successful migration of the conceptus to the
endometrium
 High index of suspicion is critical.
 Any condition that delays or interferes with the passage of an embryo
through the fallopian tube increases the risk of ectopic pregnancy
 Most important risk factor: prior ectopic pregnancy with a recurrent risk
of 10% to 15% after first ectopic pregnancy 30% after second ectopic
pregnancy
 Others: history of tubal surgery including tubal ligation, assisted
reproductive technology, and history of pelvic inflammatory disease
(PID).
 Inflammation of the fallopian tube or disruption of tubal motility
including PID, tubal endometriosis, and salpingitis isthmica nodosa.
 Smoking and multiple lifetime sexual partners, are weakly associated
with ectopic pregnancy.
 Intrauterine devices (IUDs) are an effective contraceptive method but
inc risk to be ectopic.
INFERTILITY
 increases with age and parity, and there is a Significant increase in
nulliparous women undergoing infertility treatment.
 associated with specific treatments, including reversal of sterilization,
ovulation induction, and in vitro fertilization (IVF).
 infertility increased the odds of tubal pregnancy at least four times and
perhaps as much as 40 times, depending on etiology of infertility
SMOKING
 Alterations of tubal motility, ciliary activity, and blastocyst implantation are
associated with nicotine intake (dose dependent).
PRIOR ECTOPIC PREGNANCY
 Strongest risk factor for another occurrence.
 d/t previous factors that led to damage to the fallopian tube from the
prior ectopic pregnancy and its treatment.
 Tubal patency is affected by methotrexate (72% of women had bilateral
tubal patency, 19% had unilateral tubal patency, and 3% had bilateral
tubal obstruction.
 HSG is not indicated or cost-effective after methotrexate treatment
TUBAL SURGERY
 tubal surgery is associated with an increased risk for ectopic
 pregnancy,
 Although tubal sterilization remains one of the most effective forms of
contraception and pregnancy is unlikely, failures do occur; when they
do, they are more likely to result in ectopic gestation
 The risk depends on the sterilization technique and the woman’s age at
the time of sterilization:
 postpartum partial salpingectomy and unipolar coagulation have the
lowest rates of ectopic pregnancy while bipolar coagulation techniques
had the highest incidence
 Women younger than 28 years at the time of
 sterilization are more likely to have a failure than women over 34 years.
 Sterilization reversal increases risk for ectopic pregnancy.
  Abdominal pain is the most common presenting symptom. Pain may be
Depends on the method of sterilization, site of tubal occlusion, residual
tube length, coexisting disease, and surgical technique. In general, the
risk of any
 pregnancy after a reanastomosis of a cauterized tube is up to 8% for
laparoscopic procedures.
Pelvic Infection
 Laparoscopically proven PID, the incidence of tubal obstruction
increased with successive episodes of PID: 13% after one episode, 35%
after two, and 75% after three
 Chlamydia is an important pathogen causing tubal damage and
subsequent tubal pregnancy.
 Women at risk for chlamydia infections should be diligently tested,
treated when infection is present, and counseled about the risk of ectopic
pregnancy.
CONTRACEPTIVE USE
 all contraceptive use reduces the overall risk of ectopic pregnancy
 Hormonal and copper-containing IUDs are highly effective at
 preventing intrauterine and extrauterine pregnancies
 In the rare case that women conceive with an IUD in place the pregnancy
is more likely to be ectopic.
DIAGNOSIS
 Asymptomatic cases to acute abdomen and hemodynamic shock. Until
the location of the pregnancy is confirmed, the diagnosis remains a
pregnancy of unknown location.
 Differentials of pregnancy of unknown location: early viable intrauterine
pregnancy, early nonviable intrauterine pregnancy, stable ectopic
pregnancy and unstable
 ectopic pregnancy
 Management of a ruptured ectopic pregnancy is directed at the primary
goal of achieving hemostasis, the management of a pregnancy of
unknown location in a stable patient is varied and depends on many
patient and pregnancy-specific factors.
 Maintain a high degree of suspicion of ectopic pregnancy with
pregnancies of unknown location
 History and physical examination identify patients at risk, improving the
probability of detection of ectopic pregnancy before rupture occurs.
HISTORY
 Include the patient’s age, menstrual history, previous pregnancy,
infertility history, current contraceptive status, risk factor assessment, and
current symptoms.
 Classic symptom triad of ectopic pregnancy is pain, amenorrhea,
and vaginal bleeding (in ruptured ectopic pregnancy)
unilateral or bilateral and may occur in the upper or lower abdomen.
 The patient may experience transient relief of the pain, as stretching of
the tubal serosa ceases. Shoulder and back pain, thought to result from
peritoneal irritation of the diaphragm may indicate intra-abdominal
hemorrhage
Physical Examination
 Findings before rupture and hemorrhage are nonspecific and vital signs
are normal.
 Abdomen may be nontender or mildly tender; may be slightly enlarged
with findings similar to a normal pregnancy
 An adnexal mass may be palpable but the mass varies markedly in size,
consistency, and tenderness.
 Palpable mass may be the corpus luteum and not the ectopic pregnancy.
 With rupture and intra-abdominal haemorrhage:
 Tachycardia followed by hypotension.
 Bowel sounds are decreased or absent.
 Abdomen is distended with marked tenderness and rebound
tenderness
 Cervical motion tenderness is present
LABORATORY
 Quantitative β-human chorionic gonadotropin (β-hCG) diagnostic
cornerstone for ectopic pregnancy.
 Urine pregnancy tests can detect β- hCG at ≥20 mIU/mL while serum
pregnancy tests can detect levels >5 mIU/mL.
 a-hCG levels peak at approximately 10 weeks gestation and the average
peak level is 100,000 with a wide normal range of variation. There is the
possibility of a phantom β-hCG, in which the presence of heterophile
antibodies or proteolytic enzymes causes a low level false-positive serum
β-hCG result.(not excreted in the urine, resulting in a negative urine
pregnancy test).
 In the patient with a-hCG levels less than 1,000 mIU/mL, a urine
pregnancy test should be performed and confirmatory positive results
obtained before instituting treatment
 A single β-hCG level may facilitate the interpretation of
 ultrasonography when an intrauterine gestation is not visualized.
An a-hCG level greater than the ultrasound discriminatory zone
indicates a possible extrauterine pregnancy
 Determination of serial β-hCG levels are usually needed to differentiate
an ectopic pregnancy from an intrauterine pregnancy failure
 Serial Human Chorionic Gonadotropin Level
 Serial a-hCG levels are usually required when the results of the initial
ultrasonography examination are indeterminate (i.e., when there is no
evidence of an intrauterine gestation or extrauterine findings consistent
with an ectopic pregnancy).
 Traditionally the β-hCG level was expected to rise at least 66% over 48
hours with an 85% confidence interval. About the same number of
ectopic pregnancies will have a greater than 66% rise. Data indicate
that a more conservative cut-off of 53% gives a 99% confidence
interval with less than 1% of viable intrauterine pregnancies having a
slower rise (63).
 Atleast three serial values is helpful, especially if the starting β-hCG
level is low. Follow-up research suggests that the expected rise in β-
hCG is dependent upon starting β-hCG level
 Plateau or decline in β-hCG levels, this is usually indicative of a
nonviable pregnancy. The decline in β-hCG levels can be helpful in
diagnosing a pregnancy of unknown location.
 Ectopic pregnancies will plateau or have a slower rate of decline than
spontaneous abortions.
 Most spontaneous abortions are expected to decrease 35% to 50% at
2 days and 66% to 87% at 7 days from the first laboratory test
 These expected rates of decline can aid in detecting those women at
risk for an ectopic pregnancy and warrant closer follow-up or even
intervention.
SERUM PROGESTERONE
 ≥ 25 ng/mL are associated with viable intrauterine pregnancies If the
ectopic pregnancy have a level above this threshold it is usually
associated with cardiac activity and identifiable on ultrasound.
 <5 mg/mL are associated with pregnancy failure. Less than 1% of viable
intrauterine pregnancies are below this cut-off.
ULTRASOUND
 Transvaginal ultrasound is the imaging modality of choice for pelvic
structures and the location of a newly diagnosed pregnancy.
 Earliest finding of an intrauterine pregnancy is the
 gestational sac (round, thick echogenic ring surrounding a sonolucent
center)  sac becomes eccentrically located within the endometrial
cavity.
 GS can be mimicked by an intrauterine fluid collection called a
pseudogestational sac.
 Pseudosacs occur in 8% to 29% of patients with ectopic pregnancy:
lucency, centrally located, probably represents bleeding into the
endometrial cavity by the decidual cast.
 Double decidual sac sign (DDSS) is the best method of differentiating
true sacs from pseudosacs.
 The double sac, believed to be the decidua capsularis and parietalis, is
seen as two concentric echogenic rings separated by a hypoechogenic
space.
 Pseudosacs may occasionally appear as the DDSS;
 DDSS is best observed on transabdominal ultrasound as this is
frequently missed with transvaginal
 Abdominal ultrasound reveals a DDSS with an empty-appearing
gestational sac, a transvaginal ultrasound should be performed
 The appearance of a yolk sac within the gestational sac is diagnostic of
Aa intrauterine pregnancy
 Diagnosing an ectopic pregnancy: In the absence of an intrauterine
pregnancy, if an adnexal gestational sac with a yolk sac or an embryo
is present this is diagnostic of an ectopic pregnancy.
 Adnexal rings (fluid sacs with thick echogenic rings) are visualized in
less than 50% of ectopic pregnancies. The adnexal ring may not
always be apparent because bleeding around the sac results in the
appearance of a nonspecific adnexal mass. Complex or solid
adnexal masses are frequently associated with ectopic pregnancy
 The presence of free culde- sac fluid is frequently associated with
ectopic pregnancy  tubal ruture
 the level of β-hCG where an intrauterine pregnancy should be
visualized. from 1,000 to 2,000 mIU/mL but raising the discriminatory
zone to 3,510 mIU/mL in order to avoid false results for an abnormal
pregnancy. Levels of β-hCG do not correlate with the size of ectopic
pregnancy. Regardless of how high the β- hCG level may be,
nonvisualization of the pregnancy outside the uterus does not exclude
ectopic pregnancy.
 An ectopic pregnancy may be present anywhere in the abdominal
cavity, making ultrasonographic visualization difficult.
Culdocentesis
. medical interventions and reducing the need for surgical management,
DILATATION AND CURETTAGE
 performed when the pregnancy is confirmed to be nonviable or is not
desired and the location of the pregnancy cannot be determined by
ultrasonography.
 The decision to evacuate the uterus in the presence of a positive
pregnancy test must be made with caution to avoid the unintentional
disruption of a viable intrauterine pregnancy.
 Can be accomplished under local anesthesia on an outpatient basis.
 It is essential to confirm the presence of trophoblastic tissue as rapidly as
 possible so that therapy may be instituted. (sent to pathology for formal
evaluation).
 In this case, the presence of chorionic villi may be assessed rapidly with
frozen section analysis, which avoids the waiting period of at least 48
hours for permanent histologic evaluation
 Immunocytochemical staining techniques can be used to differentiate
 intermediate trophoblasts from decidual tissue
 After tissue is obtained by curettage, it can be added to saline, in which it
will float. Decidual tissue does not float. Chorionic villi are usually
identified by their characteristic lacy frond appearance
 It is important to identify a gestational sac.If suspicion for a heterotopic
pregnancy is high the presence of villi and a gestational sac still warrants
further investigation.
 If chorionic villi are not confirmed β-hCG levels should be monitored.
After evacuation of an abnormal intrauterine pregnancy, the β-hCG level
decreases by greater than 15% within 12 to 24 hours. It has been
suggested that a fall of ≥50% within 24 hours following manual vacuum
aspiration is predictive of an abnormal intrauterine pregnancy (85).
 A repeat level should be obtained in 24 to 48 hours to confirm the
decline. If the uterus is evacuated and the pregnancy is extrauterine, the
β-hCG level will plateau or continue to increase, indicating the presence
of extrauterine trophoblastic tissue
Laparoscopy
 gold standard for the diagnosis of ectopic pregnancy. At the time of
laparoscopy, the fallopian tubes are easily visualized and evaluated, but
the diagnosis of ectopic pregnancy is missed in 3% to 4% of patients who
have very small ectopic gestations.
 The ectopic gestation is seen distorting the normal tubal architecture.
With earlier diagnosis, the possibility increases that a small ectopic
pregnancy may not be visualized.
 Pelvic adhesions or previous tubal damage may compromise
assessment of the tube.
 False-positive results occur when tubal dilation or discoloration is
misinterpreted as an ectopic pregnancy, in which case the tube can be
incised unnecessarily and damaged.
 More ectopic pregnancies are being diagnosed earlier allowing for
thus laparoscopy is no longer considered the gold standard
for diagnosis.
ALGORITHM: transvaginal ultrasonography is used as follows:
1. The identification of an intrauterine gestational sac with yolk sac
excludes the presence of an extrauterine pregnancy. If the patient
has a β-hCG level of more than 3,510 mIU/mL, and no intrauterine
gestational sac is identified, the patient is considered to have an
extrauterine pregnancy and can be treated without further testing.
2. Adnexal gestational sac with a yolk sac or embryo, when seen,
definitively confirms the diagnosis of ectopic pregnancy.
3. A tubal mass as small as 1 cm can be identified and characterized.
 Suction curettage is used to differentiate nonviable intrauterine
pregnancies from ectopic gestations (less than 53%, or even as low as
35%, rise in a-hCG level over 48 hours, an a-hCG level of less than
3,510 mIU/mL, and indeterminate ultrasonography findings).
Performance of this procedure avoids unnecessary use of methotrexate
in patients with abnormal intrauterine pregnancy that can be diagnosed
only by evacuating the uterus
 An unlikely potential problem with suction curettage is missing either an
early nonviable intrauterine pregnancy or combined intrauterine and
extrauterine pregnancies.
TREATMENT
 Ectopic pregnancy can be effectively treated medically or surgically.
 With techniques available that allow for early detection, including serum
quantitative β-hCG levels and ultrasound, more conservative treatment
options are available.
 Minimally invasive surgical techniques and medical management with
methotrexate are the commonly used treatment options for ectopic
pregnancies.
SURGICAL TREATMENT
 Operative management is the most widely used treatment for ectopic
pregnancy.
 The surgical approach (laparotomy vs. laparoscopy) and procedure
 (salpingectomy vs. salpingostomy) used to treat ectopic pregnancies
depend on the clinical circumstances, available resources, and provider
skill level.
 Each approach and procedure must be individualized to best meet the
needs of the patient and provider.
LAPAROTOMY VERSUS LAPAROSCOPY
 Treatment of an ectopic pregnancy can be accomplished by laparoscopy
or laparotomy.
 The hemodynamic stability of the patient, size and location of the ectopic
mass, and the surgeon’s expertise all contribute to determining the
appropriate surgical approach.
 Laparotomy is indicated when the patient becomes hemodynamically
unstable and an expedited abdominal entry is
 required.
 A ruptured ectopic pregnancy does not necessarily require laparotomy. If
the hemoperitoneum cannot be evacuated in a timely manner,
laparotomy should be considered.
Laparoscopy vs laparotomy
 laparoscopy is superior to laparotomy for management of ectopic
pregnancy.
 Indications for laparotomy: abdominal pregnancy, extensive abdominal or
pelvic adhesive disease, and any other condition making laparoscopy
difficult or unsafe
 Patients treated by laparotomy had significantly more adhesions at the
surgical site than those treated by laparoscopy, but tubal patency rates
were similar.
 salpingostomy was associated with decreased cost, operative time, blood
loss, and hospital stay when compared to salpingostomy at the time of a
laparotomy.
 An alternative to laparoscopy is the use of a mini-laparotomy incision.
This
 approach has the advantage of not requiring laparoscopic equipment and
utilizes a smaller incision that should result in decreased postoperative
pain and shorter recovery times for patients.
SALPINGOSTOMY
 Linear salpingostomy can be considered when the patient has an
unruptured ectopic pregnancy, wishes to retain her potential for
future fertility, and the affected fallopian tube appears otherwise normal
 In a salpingostomy, the products of conception are removed through an
incision made into the tube on its antimesenteric border. The procedure
can be accomplished with needle-tip cautery, laser, scalpel, or scissors.
It can be done with operative laparoscopic techniques or via a
laparotomy.
 Contraindications: include ruptured fallopian tube, use of extensive
cautery to obtain hemostasis, severely damaged tube and recurrent
ectopic pregnancy in the same tube.
 The main risk of salpingostomy is a persistent ectopic pregnancy
resulting from failure to remove the entire pregnancy
 Patients with high starting β-hCG levels, early gestations, and small
ectopic pregnancies (<2 cm) are at greater risk of having a persistent
pregnancy after a salpingostomy
 weekly β-hCG levels should be followed to ensure complete resolution of
the ectopic pregnancy.
 β-hCG levels that persist or plateau can usually be treated successfully
with a single dose of methotrexate.
REPRODUCTIVE OUTCOME
 Evaluated by determining tubal patency by HSGs, the subsequent
intrauterine pregnancy rate, and the recurrent ectopic pregnancy rate.
 Tubal patency on the ipsilateral side after conservative laparoscopic
management is about 84%.
 However, if the patient had evidence of tubal damage, pregnancy rates
(42%) were significantly lower than in those women who did not have
tubal damage (79%).
 Salpingostomy is associated with higher rate of repeat ectopic pregnancy
MEDICAL THERAPY
 The drug most frequently used for medical management of ectopic
pregnancy is methotrexate.
 Given systemically (intravenously, intramuscularly, or orally) or locally
(laparoscopic direct injection, ultrasound-guided injection)
METHOTREXATE
- folic acid analog that inhibits dehydrofolate reductase and thereby
prevents synthesis of DNA.
- Methotrexate affects actively growing cells including trophoblastic
tissues, malignant cells, bone marrow, intestinal mucosa
- used extensively in the treatment of gestational trophoblastic disease
- Methotrexate may be given for the treatment of persistent ectopic
pregnancies that fail surgical management.
- Methotrexate therapy can be considered for patients with confirmed, or
high suspicion for ectopic pregnancy who are hemodynamically stable
with no evidence of rupture.
- Prior to the administration of methotrexate, a patient should have a
complete blood count, blood type, liver function tests, electrolyte panel
including creatinine, and a chest x-ray if there is any history of pulmonary
disease.
- These studies are usually repeated 1 week after administration of
methotrexate to evaluate for any potential complications from the therapy
- Patients with β-hCG levels greater than 5,000 mIU/mL have a 14.3%
chance of treatment failure compared to only 3.7% for women with levels
less than 5,000 mIU/m
- Compared with the multidose protocol, single-dose methotrexate is less
expensive, patient acceptance is greater because less monitoring is
required during treatment.
Patient Follow-Up
- After IM administration of methotrexate, regardless of the dose regimen
used, patients are monitored on an outpatient basis with weekly β-hCG
levels. These levels need to be monitored until the β-hCG reaches
nonpregnant levels.
- WOF: Signs of a tubal rupture include severe pain, hemodynamic
instability, and a drop in hematocrit. Patients who report severe or
prolonged pain should be evaluated by measuring hematocrit levels and
performing transvaginal ultrasonography.
- TVS: Cul-de-sac fluid is a common finding and the amount of fluid may
increase if a tubal abortion occurs. It is not necessary to intervene
surgically, unless the patient has a precipitous drop in hematocrit
levels or she becomes hemodynamically unstable.
- Side Effects: nausea, vomiting, stomatitis, and abdominal pain. Women
are cautioned against using alcohol and nonsteroidal anti-inflammatory
medications during treatment with methotrexate.
- Other side effects include bone marrow suppression, hemorrhagic
enteritis, alopecia, dermatitis, elevated liver enzyme levels, and
pneumonitis.
- Leucovorin can reduce the incidence of these side effects and is included
in the “multidose” regimen.
ABSOLUTE CONTRAINDICATIONS OF METHOTREXATE

REPRODUCTIVE OUTCOMES OF METHOTREXATE

 Reproductive function after methotrexate treatment can be assessed
on the basis of repeat ectopic pregnancy rates, tubal patency, and
pregnancy outcome.
 The risk of subsequent ectopic pregnancy is approximately 10%
following either methotrexate or salpingostomy
 Subsequent spontaneous intrauterine pregnancy rates are similar
between those women treated with methotrexate versus
salpingostomy,
 Studies evaluating ovarian reserve after treatment with methotrexate
for an ectopic showed no impact on future ovarian reserve.
TYPES OF ECTOPIC PREGNANCY
1. Spontaneous Resolution of Pregnancies of Unknown
Location
 May resolve by resorption or by tubal abortion, obviating the
need for medical or surgical therapy.
 No specific criteria for predicting successful spontaneous
resolution of an ectopic pregnancy.
 Falling β-hCG level is the most common indicator used, but
tubal rupture can occur even with falling β-hCG levels.
 Low initial levels of β-hCG are generally the best candidates for
expectant management (beta-hCG level less than 1,000
mIU/mL; Ectopic mass less than 3 cm; No fetal heartbeat and
Compliant) has successful spontaneous remission with an
initial β-hCG level less than 200 mIU/mL.
 Follow-up with serial β-hCG levels, with a plan to initiate active
management if levels plateau or rise or signs suggestive of
tubal rupture occur.
2. Persistent Trophoblastic Tissue
 Patient underwent conservative surgery (e.g., salpingostomy,
fimbrial expression) and viable trophoblastic tissue remains.
 Histologically: no identifiable embryo, the implantation usually
is medial to the previous tubal incision an residual chorionic villi
are confined to the tubal muscularis.
 Peritoneal trophoblastic tissue implants may be responsible for
persistence.
 Diagnosis: β-hCG levels plateau after conservative surgery.
 Risk factors: type of surgical procedure, the initial β- hCG level,
the duration of amenorrhea, and the size of the ectopic
pregnancy, with smaller, earlier pregnancies treated by
salpingostomy carrying the highest risk. Patients treated with
laparoscopic salpingostomy have a higher rate of persistent
ectopic pregnancies
 Management: either repeat salpingostomy or, more
commonly, salpingectomy.
 For Patients who are hemodynamically stable at the
time of diagnosis. Methotrexate may be the treatment of
choice because the persistent trophoblastic tissue may
not be confined to the tube.
3. Nontubal Ectopic Pregnancy
 The majority in the ampulla portion of the fallopian tube
 These nontubal ectopic pregnancies are rare but are important
to consider as they are associated with more adverse events
caused by difficulty and delay in diagnosis and treatment.
a) Cervical Pregnancy
 Rarest of all ectopic pregnancies, accounting for less than 1%
of all ectopic pregnancies
 Diagnosis may not be suspected until the patient is undergoing
suction curettage for a presumed incomplete abortion and
hemorrhage occurs.
 Bleeding is light, whereas in others there is hemorrhage
 Distinguished from ongoing spontaneous abortion mainly with
ultrasound findings, and serial β-hCG measurements.
 DIFFERENTIALS: pregnancy include cervical carcinoma,
cervical or prolapsed submucosal leiomyomas, trophoblastic
tumor, placenta previa, and low-lying placenta
 CERVICAL ECTOPIC PREGNANCY UTZ CRUTERIA
 Management: treatment with methotrexate and surgical
dilation and curettage.
 The ideal regimen for medical management is unknown and
success is reported with both the single- and multidose
regimens.
 More advanced gestations, especially with fetal cardiac activity,
may require a combination of multidose methotrexate and
intra-amniotic/intra-fetal injection of KCl for fetal demise.
 These injections require skill to avoid rupture of membranes
during the procedure
 Preventative surgical management may be done. Preoperative
preparation should include blood typing and cross-matching,
establishment of intravenous access, and detailed informed
consent. This consent should include the possibility of
hemorrhage that may require transfusion or hysterectomy.
 When a cervical ectopic pregnancy presents with bleeding or if
bleeding occurs as part of treatment, various techniques can
be used including uterine packing, UAE, lateral cervical suture
placement to ligate the lateral cervical vessels, placement of a
cerclage, and insertion of an intracervical 30-mL Foley catheter
for cervical tamponade. When none of these methods is
successful, hysterectomy is required.
b) Ovarian Pregnancy
 3% of all ectopic pregnancies and is the most common type of
nontubal ectopic pregnancy. Though the
 Clinical presentation: bleeding, abdominal pain, and positive
pregnancy test is similar, ovarian pregnancy is NOT associated
with PID, infertility, or tubal disease like other ectopic
pregnancies.
 Ultrasound criteria are difficult as findings are typically a cystic
ovarian mass, with a differential of corpus luteum cyst,
hemorrhagic cyst, and tubal ectopic pregnancy.
 Management: ovarian cystectomy and/or wedge resection is
utilized with success and successful treatment with
methotrexate has been reported.
c) Abdominal Pregnancy
 rarest types of ectopic pregnancy, representing 1% to 1.4% of
ectopic pregnancies
 cprimary or secondary.
 Primary abdominal: ectopic pregnancy have been established
by Studdiford (see Table 32-8) and
 include normal tubes and ovaries, no evidence of
uteroplacental fistula.

 Secondary abdominal pregnancies are more common, thought
to result from tubal abortion or rupture or, less often, from
subsequent implantation within the abdomen after uterine
rupture.
 Risk factors: PID, multiparity, endometriosis, assisted
reproductive techniques, and tubal damage.
 Most common area of implantation: posterior culde- sac,
and pregnancies have been confirmed in the mesosalpinx,
omentum and bowel, liver, spleen, abdominal wall, and within
broad ligament.
 Abdominal pregnancy is associated with high morbidity and
mortality
 Diagnosis: Ultrasound: gestational sac surrounded by loops of
bowel, normal-appearing fallopian tubes, and ovaries
 DifferentialS: intrauterine pregnancy with retroflexion or
distorted by fibroids.
 When diagnosis is highly suspected, MRI may be helpful in
assessing degree of vascular attachment to other
abdominopelvic tissues.
 Abdominal ectopic pregnancies are one of the few ectopic
pregnancies that may proceed out of the first trimester.
 In advanced abdominal pregnancy: painful fetal movement,
fetal movements high in the abdomen or sudden cessation of
movements.
 Physical examination: persistent abnormal fetal positioning,
abdominal tenderness, a displaced uterine cervix, easy
palpation of fetal parts, and palpation of the uterus separate
from the gestation.
 Diagnosis: no uterine contractions after oxytocin infusion.
 Management: continue to term, the potential maternal
morbidity and mortality are very high. As a result, surgical
intervention is recommended.
 At surgery, the placenta can be removed if its vascular supply
can be identified and ligated, but hemorrhage can occur,
requiring abdominal packing that is left in place and removed
after 24 to 48 hours.
 Options for management of hemorrhage include artery
embolization. If the vascular supply cannot be identified, the
cord is ligated near the placental base, and the placenta is left
in place.
 Placental involution can be monitored using serial
ultrasonography and assessment of β-hCG levels.
 Potential complications of leaving the placenta: bowel
obstruction, fistula formation and sepsis as the tissue
degenerates.
 methotrexate treatment in abdominal pregnancieS
increased risk of infection and sepsis resulting from the rapid
tissue necrosis that occur following methotrexate
administration.
d) Interstitial Pregnancy
 2.4% of ectopic pregnancies
 Relatively thick with an increased capacity to expand prior to
rupture. This ability along with increased
 Vascularity of this area may allow these types of ectopic
pregnancies to remain asymptomatic for 7 to 16 weeks of
gestation.
 Most patients typically present between 6 and 8 weeks of
gestation.
 Differential diagnosis: angular pregnancy (viable pregnancy
that implants within the uterine angle, medial to the ostia).
Typically angular pregnancies are asymptomatic unless they
end in miscarriages, which occurs approximately 38% of the
time
 laparoscopy, these can be distinguished as a true interstitial
pregnancy appears lateral to the round ligament.
 ManagemenT: laparotomy with cornual resection. Early
detection allows for a more conservative management
approach in hemodynamically stable patients without evidence
of rupture.
 Medical management: methotrexate is well described, with the
single- and multidose regimens.
 Approximately 10% to 20% of patients treated medically will
ultimately require surgery and close follow-up is warranted as
with all medically managed ectopic pregnancies (141).
 Laparoscopic approaches are more widely used and are
dependent on surgical skill.
 Transcervical suction evacuation under laparoscopic or
ultrasound guidance has been reported.
e) Cesarean Scar Ectopic Pregnancy
 within the uterine myometrium at the site of a healed cesarean
 as cesarean deliveries are becoming more common, incidence
has been slowly increasing with estimations among women
with prior cesarean deliveries.
 Ultrasound is the initial diagnostic tool for CSP, with signs
suggestive of CSP including: (1) gestational sac located at the
level of the prior scar; (2) surrounding Doppler flow with
minimal separation from bladder; (3) outward bulging of the
gestational sac within the scar; and (4) negative “sliding organs
sign” where the gestational sac does not move with gentle
pressure from transvaginal ultrasound.
 two types based on prognosis; type 1 progressing toward
uterine cavity; type 2 progressing toward the bladder.
 Management: NO management that has proved superior. Early
treatment is recommended, as CSP can progress into
placental accreta or even uterine rupture if left untreated.
 Management options include medical management with
systemic or local injection of either methotrexate or KCl,
surgical management with dilation and curettage with or
without hysteroscopy
 Medical management should only be offered to
hemodynamically stable patients.
 For surgical management, dilation and curettage under
ultrasound guidance had a reported success rate of 76%
 Hysteroscopic resection was used with a 62% risk of persistent
trophoblastic disease and should be performed in combination
with dilation and curettage.
 Methotrexate followed by dilation and curettage has been
reported with success
 rates up to 86%, hemorrhage risk of 14%, and hysterectomy
risk of 4%. UAE can be performed prior to dilation and
curettage or even prior to methotrexate therapy to reduce
hemorrhage risk.
f) Heterotopic Pregnancy
 intrauterine and ectopic pregnancies coexist.
 Diagnosis: delayed as an intrauterine pregnancy is seen during
ultrasonography examination and an extrauterine is
overlooked.
 Patients undergoing ovulation induction with assisted
reproductive technology are at risk of ovarian hyperstimulation
syndrome (OHSS), which can cause similar ultrasound findings
including enlarged ovaries and free fluid in the abdomen and is
important to consider in differential diagnosis
 Serial β-hCG levels are not helpful because the intrauterine
pregnancy causes the β-hCG level to rise appropriately.
 Management. The ectopic pregnancy is treated surgically if the
intrauterine pregnancy is desired.
 When the ectopic pregnancy is removed, the intrauterine
pregnancy continues in most patients. The rate of spontaneous
abortion is higher with approximately one in three ending in
miscarriage.
 It may be possible to treat the ectopic pregnancy using non
chemotherapeutic medical treatment, such as KCl, by
transvaginal or laparoscopically directed injection.
g) Multiple Ectopic Pregnancies
  Twin or multiple ectopic gestations occur less frequently than
heterotopic gestations
 Multiple ectopic pregnancies are thought to be rare, but with
the advent of assisted reproductive technologies the incidence
appears to be rising.
 50% of these twin tubal pregnancies were associated with
assisted reproductive technologies
 Management is similar to that of other types of ectopic
pregnancy and is somewhat dependent on the location of the
pregnancy.
 removal and systemic
PREGNANCY AFTER HYSTERECTOMY
 The most unusual form of ectopic pregnancy is one that occurs
after vaginal or abdominal hysterectomy. Such a pregnancy
may occur after supracervical hysterectomy because the
patient has a cervical canal that may provide intraperitoneal
access.
 Pregnancy may occur in the perioperative period with
implantation of the already fertilized ovum in the fallopian tube.
 Pregnancy after total hysterectomy probably occurs secondary
to a vaginal mucosal defect that allows sperm into the
abdominal cavity management options include surgical
NOTES FROM PPT:
 MEDICAL MANAGEMENT: beta-hCG level less than 15,000
mIU per Ml; Reliable and able to follow-up and if
Asymptomatic
 SALPINGOSTOMY: Remove unruptured pregnancy usually <2
cm in length in distal third of fallopian tube
 SALPINGOTOMY Incision is closed
 SALPHINGECTOMY Severely damaged tube is resected.
There is uncoltrolled bleeding and tubal pregnancy is >5cm